RESEARCH PASSPORT
Occupational Health Assessment Questionnaire
[This template taken from Research in the NHS – HR Good Practice Resource Pack is the minimum standard expected.
Current version of Pack available at: www.nihr.ac.uk/systems/Pages/systems_research_passports.aspx]
Occupational Health Assessment Questionnaire
This form contains confidential medical information and must not be copied or forwarded to anyone outside
the occupational health service of the researcher’s substantive employer/place of study. Only with the
researcher’s consent may any confidential information about the researcher be discussed with the
occupational health service of NHS organisations where the researcher wishes to conduct research.
The purpose of this health assessment is to ensure, so far as is possible, that you are fit for the research
activities you will be undertaking in order to protect your own and others’ health and safety.
Questions are asked about your past and present health, medical treatment and any impairment which may
have implications for health and safety.
Please see guidance notes for infectious diseases and vaccinations attached to this form
Please note a response to your Health questionnaire will be issued within 14 days.
If you have any difficulties completing this form or wish to discuss any issues in a confidential setting please
contact the occupational health department on Tel: 0191 208 7344 for advice.
1. PERSONAL DETAILS
Surname:
Prof
Forename(s):
Miss
Work Address/Place of Study:
Cost Centre No.
Tel:
Mobile:
Dr
Ms
Mr
Mrs
Other
Email:
Date of birth:
Gender: Male
Position applied for
Proposed start date
Have you attended an Occupational Health Department for screening, or
completed a Health Questionnaire previously?
Female
Yes
No
If yes, where, when and why?
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2. DESCRIPTION OF RESEARCH ACTIVITIES:
(This will enable our occupational health advisers to assess the health risk involved with your research)
Name of Research project
Please give details of the project and nature of the work involved
2.2. During your research activity will you be involved in direct contact
with patients/service users?
This includes face to face interviewers, trial coordinators and with
contact with patients. If yes describe nature of patient contact below.
Yes
No
If NO complete Section 3 and
Declaration only.
If YES please complete the full
questionnaire
2.3. Will you be undertaking exposure-prone procedures (EPP)?
Exposure-prone procedures (EPPs) are those invasive procedures
where there is a risk that injury to the worker may result in the
exposure of the patient’s open tissues to the blood of the worker.
These include procedures where the worker’s gloved hands may be in
contact with sharp instruments, needle tips or sharp tissues (e.g.
spicules of bone or teeth) inside a patient’s open body cavity, wound or
confined anatomical space where the hands or fingertips may not be
completely visible at all times.
Yes
No
If YES complete Section 4.
If NO Section 4 may be omitted.
Further information
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3. BLOOD BORNE VIRUS RISK
3.1 Will you be at risk of exposure to blood-borne viruses?
Yes
No
This includes work with human blood, tissue or cells. If so give details
of the nature of the work involved.
3.2 Hepatitis B immunisation.
Give dates of when you completed initial immunisation and your last
booster.
Please indicate if you had a blood test to confirm the effectiveness of
the immunisation.
Initial:
2nd:
3rd:
Booster:
PVS blood test*
Do you have documented evidence
of the blood test
*Documented evidence of this is required. Please attach scanned
copies to this result.
Yes
No
4. EXPOSURE PRONE PROCEDURES ASSESSMENT (IF REQUIRED)
Have you had:
Yes No
Date
Result/.Comments /Validation (For OH Use)
Hepatitis B antigen (HBsAg)
*if positive
positive//negative
Hepatitis B e antigen (HBeAg)
positive//negative
*if negative
Hepatitis is B viral load (BV DNA)
Hepatitis C antibody
copies/ml
positive/negative
HIV Antibody
positive//negative
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5. VACCINATION HISTORY
Please give details of vaccinations and tests you have had.
Have you had:
Yes
No
Date
Result/.Comments /Validation (For OH Use)
1. BCG vaccination
Scar size:
mm
2. Do you have a scar?
3. Rubella (German measles) immunisation
Documented evidence of at least 2 MMR
vaccinations required. Please attach
scanned copies to this form
4. Rubella antibody test
Documented evidence of test result
required. Please attach scanned copies to
this form.
5. Measles immunisation
Either as part of MMR or as a single measles
immunisation
Documented evidence of test result
required. Please attach scanned copies to
this form.
Immune : Yes
No
Immune : Yes
No
6. Tetanus immunisation
Give date of last booster
7. Diphtheria immunisation
8. Varicella (Chickenpox ) immunisation
Immune : Yes
9. Varicella (VZV) antibody test
No
6. CHILDHOOD INFECTIOUS DISEASES HISTORY
Please give details of childhood infectious diseases you have had. Where possible give dates.
Have you had:
Yes
No
Date
Comments /Validation (For OH Use)
Measles
Mumps
Chicken pox
German measles (rubella)
Whooping cough
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7. TUBERCULOSIS ASSESSMENT
Have you lived for a significant length of time in a
high tuberculosis risk area (Africa, Indian subcontinent or the far east)
Yes
No
Dates
Have you had a TB immunity/screening test (Heaf,
Mantoux or interferon – gamma test).
Yes
No
Date
Have you ever had a chest x-ray?
If yes please state why
Where and when was the chest x -ray done?
If yes please provide scanned documented result
Yes
No
Was it normal?
Yes
No
Have you had a cough for more than 3 weeks in the
past year?
Yes
No
Have you had any unexplained loss of weight or
fever (high temperature) in the past year?
Yes
No
Have you or anyone in your family had Tuberculosis
(T.B.)?
If YES who and when?
Yes
No
Are you being followed up for contact with infectious
Tuberculosis?
Yes
No
8. DECLARATION OF HEALTH
1. Do you currently have any health problems, including psychological
problems, or are you awaiting surgery?
Yes
No
2. Are you presently receiving any prescribed medication, treatment or
therapy except contraception?
Yes
No
4. Do you have any health or psychological condition that may affect
your ability to perform the proposed research activity?
Yes
No
5. Do you have any health condition caused or made worse by work?
Yes
No
Yes
No
Yes
No
3. How many days off sick have you had over the past two years?
6. Do you have any disability or other health condition not mentioned
above that may require additional help or support to perform the
research activity?
7. Have you been working abroad in the last 12 months?
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If you have answered ‘yes’ to any of the above, please give details including dates and how it affects you
now. Continue on a separate sheet if necessary.
Question
Further details
1.
2.
3.
4.
5.
6.
7.
9. DECLARATION
The information in this form is true and complete. I agree that any deliberate omission, falsification or
misrepresentation in the form may be grounds for rejecting this application and/or subsequent disciplinary
action.
I consent to relevant health information about me being shared between the occupational health service of
my employer/place of study and the occupational health service of any NHS organisations where I wish to
undertake research activities. I hereby agree to inform the occupational health service of my employer/place
of study and of any NHS organisations where I will be conducting research activities of any changes in my
health circumstances that may affect my ability to perform the research activity.
I understand my responsibility to notify the occupational health service of my employer/place of study and of
any NHS organisations where I will be conducting research activities if I think I have had significant exposure
to, or am carrying, a serious communicable condition such as Hepatitis B, Hepatitis C or HIV and to follow
advice from a consultant in occupational health or another suitably qualified colleague about treatments
and/or modifications to my practice.
I understand the importance of routine infection-control procedures, including the importance of hand
hygiene, appropriate use of protective clothing and compliance with local policies in the NHS organisations
where I wish to undertake research activities.
Signed:
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FOR OCCUPATIONAL HEALTH SERVICE USE
INITIAL DECISION
FIT ON QUESTIONNAIRE
FURTHER INFORMATION
REQUIRED
CLINIC ASSESSMENT REQUIRED
SEE ON COMMENCEMENT
DATE

COMMENT/ ACTION
 NHS TRUST/HR INFORMED


 HR/ MANAGER INFORMED
 APPOINTMENT ARRANGED

 HUMAN RESOURCES INFORMED
 APPOINTMENT ARRANGED
Date_______________
__________________
Date_______________
Date_______________
Date_______________
Date_______________
Notes ____________________________________________________________________________________________
_________________________________________________________________________________________________
CLINIC TESTS
SPECIFY
RESULTS
FINAL DECISION
RECOMMNEDATIONS /COMMENT
FIT TO UNDERTAKE RESEARCH

FIT FOR PATIENT CONTACT

FIT FOR EPP

FIT WITH RESTRICTIONS

UNFIT

OH Physician / Adviser’s signature _____________________________ Date _________________________
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CERTIFICATE OF FITNESS FOR RESEARCH PASSPORT
Name:
Position:
Date of Screening
Research Protocol :
Chief Investigator :
School/Service/Institute :
Project Start Date
Following review of the pre placement health screening questionnaire the above person is considered
to be : ( tick appropriate)

Fit to undertake research project work within HEI

Fit for patient contact

Fit with restrictions( specify):

Unfit

Fit for Exposure Prone Procedures

Unfit for EPP
Occupational Health Newcastle University
Name
OH Physician/ Practitioner / Advisor
Title
Signature
Date

Forward to Newcastle Trust for MRSA screening
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Guidance Note
Infectious Diseases Screening for Research Passport
Rubella (German Measles)
Rubella infection during pregnancy poses a significant threat to the developing baby.
All health care workers (which includes researchers) with direct patient contact who are not
immune to rubella must be immunised using the MMR (measles, mumps, rubella) vaccine unless
documented evidence of two doses of MMR vaccine rubella immunity is available.
A past history of the illness or of vaccination alone is not sufficient evidence of immunity.
The candidate must produce documentary proof of two doses of MMR vaccine or rubella immunity
demonstrated by blood test. If this is not possible give a course of MMR vaccine. There is no
need to carry out a further blood test.
Varicella (Chicken Pox)
The Chief Medical Officer has recommended that health care workers (which includes researchers)
with direct patient contact who are not immune to chicken pox should be immunised using the
chicken pox vaccine.
This is recommended to protect susceptible workers and also to protect vulnerable patients from
acquiring chickenpox from an infected member of staff.
Those candidates who are UK born with a good history of chickenpox or shingles can be
considered immune to varicella. Those who do not have such a history or were born outside of the
UK should be checked for antibodies to varicella and informed of the result; in the vast majority of
cases, they will be found to be immune.
Those found to be susceptible should be offered immunisation against varicella, provided
immunisation is not contra-indicated in that individual:
The following staff are required to be immune to varicella



staff routinely working with immunocompromised patients
staff in the adult and paediatric infection diseases units
and staff routinely working with neonates
Contra-indications to the vaccine include pregnancy, immunosuppression due to disease or
treatment, and previous hypersensitivity reactions to the vaccine.
People immunised with this vaccine may develop a varicella-like rash following the first or second
dose. All such rashes must be reported to Occupational Health. If the rash is generalised, then the
staff member should be excluded from work until all lesions are crusted over and no new lesions
are appearing. Localised rashes may be kept covered and the staff member allowed to continue
working, but if the staff member works with immunocompromised patients, or paediatric patients
his/her status should be reviewed by Occupational Health and infection control on an individual
basis.
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Tuberculosis
Persons carrying out research in the NHS who have direct contact with patients or work with
clinical specimens should not start work until they have completed a TB screen or health check, or
until documentary evidence is provided of such screening having taken place within the preceding
12 months.
If the candidate has had a health screen for tuberculosis within the last twelve months ask them to
provide documentary evidence.
If they have received BCG vaccine check for the presence of a BCG scar or obtain documentary
evidence of successful BCG to confirm this.
If they have not had BCG vaccine for tuberculosis or a BCG scar is not evident and documentary
evidence is not available, carry out an interferon-gamma test for latent TB. This test does not
indicate TB immunity and is not affected by previous BCG vaccination. A positive result indicates
the possibility of latent tuberculosis. Staff should be advised that they may have encountered
tuberculosis in the past and that they do not need a BCG vaccination. They should be advised to
report suspicious symptoms should they arise in the future. However, staff coming to work in the
UK from countries with a high incidence of tuberculosis should be referred to the chest clinic for
clinical examination and chest X-ray, even if they are asymptomatic.
If the candidate has not had BCG or a BCG scar is not evident a risk assessment for TB exposure
should be carried out.
High risk areas include:






Work in neonatal and maternity units
Work in mortuaries
Work in respiratory medicine
Work with people from high risk areas
Work with clinical specimens which may pose a risk such as sputum specimens.
Work with immunocompromised patients.
Candidates in these areas should be assessed for TB immunity. Evidence of immunity includes:



documented evidence of previous BCG immunisation
a history of immunisation plus BCG scar
a history of immunisation without a BCG scar but with a documented positive Heaf test of
grade 2 or more (or a positive Mantoux test with 6-15mm of induration) within the last five
years
No further action is required if the above criteria are satisfied. Otherwise a Mantoux test should be
performed and a BCG vaccination offered when the test result shows induration of less than 5mm.
If BCG is given, there is no need to inspect the site of vaccination at a later date for the presence
of a scar, and repeat Mantoux testing and repeat BCG immunisations are unnecessary.
It should be remembered that the period between immunisations and scar development, the staff
member will not be fully protected against tuberculosis. The activities of the staff member during
this period should be reviewed by Occupational Health and the infection control team to assess the
potential risk to the staff member and to patients.
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If a member of staff refuses to have a BCG or cannot be immunised for other reasons, this fact
should be recorded and the risks explained to him/her.
Asymptomatic staff who have Mantoux test results with an area of induration of 6mm or more
should not be automatically referred for a chest x-ray, with one exception Such staff should be
advised that they may have encountered tuberculosis in the past and that they do not need a BCG
vaccination. They should be advised to report suspicious symptoms should they arise in the future.
However, staff coming to work in the UK from countries with a high incidence of tuberculosis
should be referred to the chest clinic for clinical examination and chest X-ray, even if they are
asymptomatic, if their Mantoux test result shows an area of indurations of 15mm ore more.
Tetanus / Measles / Diphtheria
The candidate should confirm immunisation status for these conditions. There is no specific
requirement for these with regard to the provision of an NHS passport but MMR vaccine is
recommended for those who have not had measles or been vaccinated against measles.
Candidates born prior to 1970 and those with a definite history of measles can be considered
immune to measles. Others should be offered immunity screening or two doses of MMR vaccine.
Hepatitis B
Candidates working with human blood, tissue or cell cultures should be immunised against
Hepatitis B.
*’Direct contact’ means face-to-face contact with patients/service users
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